If we want more evidence-based practice, we need more practice-based evidence.*

Chapter 12


Lifestyle, Population Health, and Community Health Promotion

 

TABLE OF CONTENTS

OBJECTIVES AND PHILOSOPHY
OVERVIEW
HEADLINES, TIMELINES, & MILESTONES  
WEB PAGES AND INFORMATION SOURCES
REFERENCES- since publication of 8th edition
DEBATE TOPICS
STUDY QUESTIONS, ACTIVITIES, AND EXERCISES


OBJECTIVES AND PHILOSOPHY

Lifestyle, as a concept in community and population health, runs against the grain of traditional public health ideology and methodology in two respects. First, lifestyle is individualistically conceived by some to be a psychological rather than sociological or community matter. This notion ignores the powerful social and environmental influences on individual behavior. The second views lifestyle as a matter of individual "responsibility." This implies that people are irresponsible if every aspect of their behavior is not health-directed and it assumes that they have control over the social and environmental forces shaping their behavior from infancy onward. By conceiving lifestyle as a normative product of cultural, organizational, economic and environmental forces rather than as a moral issue, this chapter identifies specific points for effective community intervention to support more healthful lifestyles. Besides the objectives identified at the beginning of the chapter, this presentation of the lifestyle and community health promotion issues should produce a more sympathetic and sociological perspective on personal health practices as they relate to health and community development.


OVERVIEW

The epidemiologies of tobacco and alcohol misuse, eating problems and drug misuse are examined to identify prospects for prevention and specific points for effective community intervention. The point is made for each of these behavioral risk factors that educational strategies directed at individuals must be supplemented with organizational, economic and environmental supports for the more healthful behavioral options.

The epidemiological triad of host, agent, and environment proves useful in presenting the balanced view of alcohol, tobacco, food, and drugs as agents whose influence on health depends on the combination of host-resistance (educational effects) and social, political, economic and other environmental effects on the availability, accessibility and acceptability of various behavioral options. Much of the current concern with these agents in Western countries is their cumulative effects on social pathology and chronic diseases, but the extreme cases of agent abuse including addictions, obesity, anorexia nervosa and bulimia are discussed as well. In developing countries, the threat and reality of hunger and malnutrition are primary, but the growing problems associated with alcohol, tobacco and drug misuse require preventive action. Finally, this chapter concludes Part 3 of the text with an application and extension of the PRECEDE model first presented in Chapter 4, showing its utility in analyzing the forces influencing complex lifestyle practices such as drug misuse.


HEADLINES, TIMELINES, & MILESTONES

New food pyramid released by USDA. Apr 21, 2005. 

New Dietary Guidelines released. The US Departments of Agriculture and Health & Human Services released the 2005 version of the periodically revised Guidelines. Jan. 12, 2005.

Ohio: Court says Master Settlement Agreement bans promo matchbooks “Court: Settlement bans cigarette ads on free matchbooks” (Associated Press, Jan 3, '05 )    

Pennsylvania: Schools see promising results from obesity campaign “School district shows early success in fighting childhood obesity” (Associated Press, Jan 1, 2005 )    

California: Cities and towns make effort to keep tobacco from minors. “Fee helps snuff out tobacco sales to minors”. Monterey County Herald   Jan 1, 2005.  M.S. Enkoji

South Carolina: Quirk in state’s tattoo law comes to light. “Tattoo law comes with sticking point”

Charlotte Observer Jan 1, 2005.  Henry Eichel

Expert Panel Finds Flaws in Diet Pill Safety Study.  (New York Times, July 23, 2003) - A House subcommittee has released a report that highlights shortcomings and flaws in a medical study of  ephedra.  The study has been used by ephedra companies to evidence the safety of the product.

Labels Will Change, but Will Diet?  (Los Angeles Times, July 21, 2003).

AA Helps Alcoholics Stay Abstinent Over the Long Term.  April 23, 2003

Web-Based Programs Have Potential To Help Smokers Quit.  April 11, 2003

Philip Morris Convicted of Fraud in Marketing.  (New York Times, March 22, 2003)  Philip Morris USA was found guilty of consumer fraud and was ordered to pay $10.1 billion for failing to inform consumers that its light cigarettes were not less harmful than full-flavored cigarettes.  Philip Morris plans to appeal the verdict passed down by an Illinois Circuit Court judge.

Dept. of Justice Sues Tobacco Cartel for $289 Billion.  (New York Times, March 18, 2003) - The department of justice has file a lawsuit against Philip Morris; R. J. Reynolds; the Loews Corporation's Lorillard Tobacco; British American Tobacco's Brown & Williamson, and the Vector Group's Liggett Group for $289 billion.  The basis of the suit is the fraudulent practices of the tobacco companies, in particular:  targeting children in ad campaigns, lying about the dangers of tobacco, and manipulating nicotine levels in cigarettes. 
 

Blackouts Common Among College-Age Drinkers.  March 13, 2003

Behavior Changes Could Sharply Cut Cancer Death Rates, Says Institute of Medicine.  March 10, 2003

Study: Black Health, Finances ImproveFebruary 27, 2003.

TV Shows Aimed at Blacks Carry More Junk-Food Ads.  (Reuters Health, February 27, 2003) - According to a recently published study, primetime television shows with predominantly African American characters contain more junk-food ads and overweight characters than other primetime shows.
 

Problem Gamblers Associate Winning With Drinking.  Feb. 20, 2003

Surgeon General Carmona, HHS Secretary Thompson Address Disease Prevention and the Obesity Epidemic. January 24, 2003

Students' Expectations, Parental History Linked to Alcohol Problems.  Jan. 14, 2003

Health Benefits of Moderate Drinking May Not Apply to African-Americans.  Jan. 14, 2003

Individuals' Medical Costs Rise With Increasing Obesity.  Jan. 10, 2003

Young Adults Lose Years of Their Lives to Obesity.  Jan. 7, 2003

Signs of Smoking Linger Longer in Menthol Smokers.  Dec. 16, 2002

Metabolism Changes After Alcohol Withdrawal May Raise Blood Pressure.  Dec. 16, 2002

Treating Alcoholism Is More Complex Than 'All or Nothing'.  Dec. 16, 2002  

Additive-Free Cigarettes May Pack a More Toxic Tobacco Punch.  Dec. 3, 2002

Air Force Recruits Need Potent Smoking Cessation Programs.  May 23, 2002

Per the following article, and contrary to decades of false claims by the tobacco industry, all leading U.S. tobacco control and health groups oppose tobacco prohibition.  Rather, governments should enact and  enforce reasonable regulations that have proven safe and effective in reducing tobacco addiction and protecting public health (e.g. 100% smoke-free indoor policies, increase tobacco taxes, repeal state and local preemption laws, repeal tobacco liability protections, halt marketing to youth, require bolder warning labels, increase funding for comprehensive tobacco control, prevention and treatment programs).  Bill Godshall

NORTH DAKOTA LEGISLATURE:  Groups question tobacco ban:  Measure would make it a misdemeanor crime to sell or use product.   Associated Press Grand Forks Herald Wednesday, Jan. 15, 2003.       

Smoking Causes Male Sexual Impotence: BMA Calls for Health Warnings.  LONDON (British Medical Assn. & Action on Smoking and Health, June 2, 1999)-  The British Medical Association and Action on Smoking and Health today publish a report Smoking and Male Sexual Problems warning that smoking is responsible for impotence in 120,000 UK men aged 30 to 49. Although the link between smoking and impotence is well-established scientifically, very few smokers are aware of the risks they are taking with their sex lives.  http://www.nietrokers.nl/e/n08069.html    

Survey Finds Long-Term Declines in Cigarette and Illicit Drug Use Among Military Personnel; Heavy Alcohol Use Remains Unchanged. (May 31,1999, 1998 Department of Defense Survey of Health Related Behaviors Among Military Personnel.) For more information contact Robert Bray at (919) 541-6000. Click here for the full report. 

Save the Kids, Fight Tobacco. (Washington Post) Op-ed by US Surgeon General David Satcher. The single most promising public health intervention today is not the development of a new drug but the opportunity to invest part of the recent $246 billion settlement with the tobacco companies into public health and proven programs that would prevent our nation's children from smoking... Effective tobacco control programs require: (1) Public education... (2) Community-based programs... (3) Treatment for tobacco addiction... (4) School-based programs... (5) Enforcement, evaluation, surveillance... We have not had a case of Y-virus polio in the United States since 1979, and we are moving rapidly toward global eradication. If we work together and make a commitment to tobacco control, one day we will be able to say the same thing about smoking-related diseases.
http://www.cleanlungs.com/settlement/surgeon.html

Alcoholism Imperils Russia. MOSCOW (AP, Mar. 10, 1999) - Alcoholism among Russian teenagers in on the rise, and drinking problems continue to afflict millions of Russians, a top health official said Wednesday. Some 2.5 million people, or nearly 2% of Russia's 146.3 population, are officially registered alcoholics, but the actual number is probably much higher, Deputy Health Minister Gennady Onishchenko told a news conference. "This is a frightening figure," he said, according to the Interfax news agency. Especially alarming is a growing number of alcoholics among teenagers, he said. There were 17.4 alcoholics per 100,000 teenagers five years ago, compared to 20.8 per 100,000 last year. In 1999, the figure may rise to 24.4, Onishchenko said.

Churches in Tobacco Growing States Struggle with Tobacco Message
(AP, Feb. 16, 1999) Churches in tobacco growing states are struggling with how to address the issue of tobacco. Some religious leaders see it as their obligation to preach about the dangers of tobacco and to raise questions about the marketing of tobacco to children and to developing countries. 

Nearly Two-Thirds of People Needing Drug Abuse Treatment Do Receive It. (CSAT and CESAR, University of Maryland) There is a large gap between the number who need and the number who receive treatment, according to an analysis of data from the National Household Survey on Drug Abuse (NHSDA). An estimated 5.3 million people were diagnosed as needing treatment for severe drug abuse problems in 1996. However, only around one-third (37%) receives treatment for drug abuse, a proportion consistent with previous years' estimates. For further information visit http://www.cesar.umd.edu

Majority of Treatment Costs for Mental Health and substance abuse Problems Paid for by Federal, State and Local Governments (CSAT and CESAR, University of Maryland) Over $79 billion was spent on treatment for mental health and substance abuse problems in 1996, according to a study recently released by the Substance Abuse and Mental Health Services Administration (SAMHSA). of this total, $66.7 billion was for the treatment of mental illness, $5 billion for the treatment of alcohol abuse, and $7.6 billion for the treatment of other drug abuse. Government funding (including Medicare, Medicaid, and other federal, state and local government programs) paid for the majority of all three types of treatment. Treatment for other drug abuse had the highest proportion of government funding (66%), while treatment for mental illness had the lowest (53%).

Drunk Driving Deaths Continue to Decline in the United States. (University of Maryland, College Park) Almost 40% of the 41,967 traffic fatalities that occurred in the United States in the 1997 were alcohol-related, according to data from the National Highway Transportation Safety Administration's Fatality Analysis Reporting System (FARS). While the percentage is a cause for concern, it represents a marked improvement over past years; alcohol related traffic fatalities have decreased from 25,165 in 1982 to 16,189 in 1997. Many factors are likely influenced this decline, including the enactment of stricter alcohol-impaired driving legislation.

1998 "Keeping Score" Report Focuses on Substance Abuse Among Women and Girls (University of Maryland, College Park) Federal funding for women's substance abuse prevention, treatment, and research programs need to be increased, according to the 1998 edition of Keeping Score, released by Drug Strategies last Friday. The annual report reviews the impact and effectiveness of public drug control spending; the 1998 edition focuses on substance use among women and girls.

Substance Abuse Costs Texas $19.3 Billion in 1997; Majority of Costs Stem From Alcohol (CSAT and CESAR, University of Maryland) The total estimated costs of alcohol and drug abuse in Texas in 1997 was $19.3 billion--an estimated $1,001 per person living in the state, Morbidity costs-- the value of lost productivity--accounted for the largest proportion of all costs (42%), followed by mortality costs--the loss of future lifetime earnings due to the premature death (20%). The primary source of both of these costs was alcohol abuse. according to the author of the report, "these findings challenge both the public and the private sectors to work together towards solutions to minimize the economic burdens of substance abuse in Texas" (p.6) A copy of the report is available on-line at http://www.tcada.state.tx.us

Survey: Eating Out is on the Rise. WASHINGTON (AP, Feb. 17, 1999) - Americans are eating more healthful meals at home but their nutritional gains are in jeopardy as more of them eat out, consuming food with more fat and less fiber, iron and calcium, a government study says. Health-conscious Americans do a good job of making sure their meals are high in fiber, iron and other nutrients when they cook at home, the report released Tuesday by the Agriculture Department found. But the proportion of meals eaten away from home nearly doubled from 16% in 1977-78 to 29% in 1995 - an upward trend that will probably continue, the government said. And meals eaten away from home haven't kept pace with the nutritional improvements in home-cooked foods.

CDC: Cigarette Tax Cuts Smoking. ATLANTA (AP, Feb. 26, 1999 - Oregon's tax hike of 30 cents per pack for an anti-tobacco campaign has resulted in an 11.3% decrease in per-capita sales of cigarettes over the past two years, according to federal health officials. Sales dropped by about 10 packs per person from 1996 to 1998, the Centers for Disease Control and Prevention reported Thursday. During the previous four years, Oregon had a 2.2% increase in sales per capita. The CDC calculated that the tax increase alone contributed to a 6.3% decline. See the following abstract of the MMWR article on which this news release is based.

Decline in Cigarette Consumption Following Implementation of a Comprehensive Tobacco Prevention and Education Program -- OREGON (1996-1998). Morbidity and Mortality Weekly Report, Vol. 48/No. 7, Feb. 26, 1999. View the full text of this week's MMWR as a web page at: http://www.cdc.gov/mmwr/preview/mmwrhtml/00056574.htmI

HHS Recommends Cigar Warning Labels. WASHINGTON (AP, Feb. 26, 1999) - Cigars, which scientists say are just as deadly as cigarettes, should carry similar health warning labels, the Department of Health and Human Servicesrecommended Friday. The report from HHS Inspector General June Gibbs Brown urges the Federal Trade Commission to require that cigar manufacturers affix a surgeon general's warning label similar to the labels carried on cigarettes and smokeless tobacco. "Given the most recent evidence about cigars, it's their view that it is time for a warning label on cigars analogous to the labels on cigarettes," HHS spokeswoman Melissa Skolfield said.

Diet May Prevent Second Heart Attacks. DALLAS (AP, Feb. 28, 1999) - A Mediterranean-style diet high in fruits, vegetables, fish and beans - already proven to reduce the risk of cancer - may also protect people from suffering a second heart attack, a study shows. A study of more than 400 men and women over nearly four years found that people who eat these kinds of foods are 50% to 70% less likely to suffer repeat heart attacks. "By making some simple dietary changes that are easy to understand and easy to follow, a person can improve his or her chances of avoiding a second heart attack and having a better quality of life," said Dr. Michel de Lorgeril, who led the French project known as the Lyon Diet Heart Study.

Diet Industry Given New Guidelines. WASHINGTON (AP, Feb. 10, 1999) - Some of the biggest names in the weight loss business have pledged to give consumers looking to shed excess pounds better information about how much diet products and programs will cost, the risks involved and the benefits of even moderate weight loss. A set of voluntary guidelines, released Wednesday by a group of government, industry and health representatives, don't reach a consensus on one of the most pressing questions - how many pounds consumers can expect to lose - but they do urge the diet industry to disclose more information to clients. "We are very happy that we have gotten this far," said Lynn McAfee of the Philadelphia-based Council on Size & Weight Discrimination.

Federal Lawsuit May Seek $0.2 Trillion. WASHINGTON (White House Press Release, Jan 20, 1999) - The Federal lawsuit against the tobacco industry announced by President Clinton in his State of the Union address this week may seek hundreds of billions of dollars to recover government costs of treating smoking-related illnesses, Administration officials said Wednesday. The administration officials said Clinton would again seek anti- smoking legislation this year to force the industry to take steps to reduce youth smoking. Clinton plans to propose in his budget request for fiscal 2000 a 55-cent-per-pack increase in the Federal cigarette tax to raise $8 billion over five years to offset the health care costs of smoking. More information on this matter is available on the World Wide Web at: http://nt.excite.com/news/r/990121/00/news-tobacco.  Numerous Web news sites may be found via this page of links: http://tigerx.com/sites/news.htm

Wine Labels May Tout Health Benefits. WASHINGTON (AP, Feb. 4, 1999) - Scientific studies have suggested it, and now winemakers finally may get a chance to tout it through their labeling: A glass or two of the grape each day could be good for you. The Treasury Department announced Friday two proposed changes for wine labels to include references to some of the positive health effects of drinking wine. Wine labels already warn that pregnant women should not drink alcohol and that alcohol can impair driving and cause health problems. But they say nothing about studies suggesting that moderate alcohol intake can reduce the risk of heart disease in some people. The change would not become final until after a public comment period that could last 90 days and a review by the Treasury Department.

Investment in Health Yields Global Returns - (Toronto Star, Feb. 4, 1999). Ill health is one of the great cost burdens faced by societies around the world. Yet it is a cost that could be much reduced if more attention was paid to investing in health rather than focusing narrowly on health care... medical doctors understand this. So it's not surprising that Gro Harlem Brundtland, a medical doctor with a graduate degree in public health, is emphasizing the determinants of health in her new job as director-general of the World Health Organization... Because of her concern about health, Brundtland is, for example, targeting tobacco as one of the principal sources of ill health in the world

Wisconsin Cirrhosis Mortality Rate Low. WASAU (AP, Jan. 4, 1999) - Surprisingly few drinkers in Wisconsin die from cirrhosis of the liver despite the state's comparatively high rate of alcohol consumption, a new medical report finds. Wisconsin, known as the dairy state, ranks as one of the top five states in per capita consumption of alcohol. Yet its death rate from liver cirrhosis, a disease linked to drinking, is among the lowest, according to a report published Wednesday in the Wisconsin Medical Journal. "We call it an ecological fallacy," said Dr. Patrick Remington, one of the researchers. The report ranks Wisconsin No. 1 in overall alcohol consumption, with 69% of adults surveyed indicating they drink alcohol.

Ministry Releases Lists of Cigarette Chemicals VICTORIA (December 16, 1998). Lists of what Canadian tobacco companies put in cigarettes and what is in the smoke from the 11 best selling brands in British Columbia were released today by Health Minister Penny Priddy. 'B.C. is the first jurisdiction in the world to require this sort of detailed testing and reporting on tobacco smoke" Priddy said. "We are also first government to release a complete list of ingredients to companies put in cigarettes". The new data on cigarette ingredients and additives and the level of selected chemicals in their smoke is now available at http://www.cctc.ca -- the internet Web site of the Canadian Center for Tobacco Control. "We want to make this information available to al Canadian and have placed it on a Web site that is known nationwide as a source of information on tobacco" Priddy said. The data can also be accessed through http://www.tobaccofacts.org. --the B.C. Health Ministry's Web site on tobacco. For more detail on this and related press releases go to: http://www.hlth.gov.bc.ca/news.html.

California Bars, Casinos Go Smoke Free (USA Today January 2, 1998.) California became the first state to ban smoking in bars and casinos.

Malboro Man Had a Certain Chemistry (A P, February 9, 1998.) It turns out that one secret to Malboro's success was ammonia that boosted the nicotine kick and improved the taste.

President Expected to Endorse Tobacco Legislation That Raises Cigarette Prices, Limits Industry Liability (CNN WEB page March 12, 1998.) The President is to announce his support of Senate tobacco legislation that would raise prices by a $1.50 a pack for two years and limit the companies’ liability.

Best deal: More FDA Clout, Fewer Teen Smokers ( USA Today August 27, 1997.) States have won several battles against the big tobacco companies but congress still needs to win the war. The article describes the settlements and the direction of future actions.

For related news stories, please click here. 


WEB PAGES AND INFORMATION RESOURCES

Websites on General Health Promotion

Websites on Eating Disorder

Websites on Smoking

Websites on Alcohol and Drug Addiction


REFERENCES

Journal References

Bach, P.B., & Lantos, J. (1999). Methadone Dosing, Heroin Affordability, And The Severity Of Addiction. AMERICAN JOURNAL OF PUBLIC HEALTH 89 (5): 662-665.
    ABSTRACT: http://www.apha.org/Journal/abstracts/abbach.htm.  The Journal's Home Page: http://www.ajph.org/.

Bachman, J.G., Freedman-Doan, P., O'Malley, P.M., Johnston, L.D., & Segal, D.R. (1999). Changing Patterns Of Drug Use Among US Military Recruits Before And After Enlistment. AMERICAN JOURNAL OF PUBLIC HEALTH 89 (5): 672-677.
    ABSTRACT: http://www.apha.org/Journal/abstracts/abbachmn.htm. The Journal's Home Page: http://www.ajph.org/.   

Fahey, J. W. (1998).  Underexploited African Grain Crops: A Nutritional Resource. NUTRITION REVIEWS 56 (9): 282.
    ABSTRACT: The African grain deficit is projected to surpass its current production of 50 x 10 6 metric tons/year by the turn of the century. The biodiversity of the African continent, on which there are more native cereals than on any other continent, can serve to reduce the vulnerability of that continent's populations at serious risk of food shortages. Traditional grain and root crops have provided the energy underpinning for Africa since ;the emergence of bipedal hominids. By resurrecting some of these "lost crops" in their native areas, the food security of those areas can be enhanced. Some of these crops lend themselves to introduction into other nutritionally challenged areas of the world with similar geoclimatic characteristics.

Glantz, S. A., & Charlesworth, A. (1999). Tourism And Hotel Revenues Before And After Passage Of Smoke-Free Restaurant Ordinances. JAMA – JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION 281: 1911-1918.
    ABSTRACT: http://jama.ama-assn.org/issues/v281n20/abs/joc81586.html.

Haapanen-Niemi, N., Miilunpalo, S., Vuori, I., Pasanen, M., &Oja, P. (1999). The Impact Of Smoking, Alcohol Consumption, And Physical Activity On Use Of Hospital Services. AMERICAN JOURNAL OF PUBLIC HEALTH 89 (5): 691-698.
    The Journal's Home Page: http://www.ajph.org/.
    ABSTRACT: Objectives. This study investigated the associations of smoking, excess alcohol consumption, and physical inactivity with the use of hospital care. Results. After adjustment for confounders, male smokers had 70% (95% confidence interval [CI] = 49%, 95%) and female smokers had 49% (95% CI = 29%, 71%) more hospital days due to any cause than did those who had never smoked. Men consuming a moderate amount of alcohol had 21% (95% CI = 10%, 31%) fewer hospital days due to any cause than did nondrinkers. Men who had the lowest energy expenditure during leisure-time physical activity had 36% (95% CI = 15%, 63%) more hospital days than the most active men. The figure for women was 23% (95% CI = 4%, 44%). Conclusions. Smoking was strongly associated with an increased use of hospital services. The associations of alcohol consumption and leisure-time physical activity with use of hospital care depended on the diagnosis under study.

Hser, Y.I., Joshi, V., Anglin, M.D., & Fletcher, B. (1999). Predicting Posttreatment Cocaine Abstinence For First-Time Admissions And Treatment Repeaters. AMERICAN JOURNAL OF PUBLIC HEALTH 89 (5): 666-671.
The Journal's Home Page: http://www.ajph.org/.
    ABSTRACT: Objectives. This study examined client and program characteristics that predict posttreatment cocaine abstinence among cocaine abusers with different treatment histories. Results. No prior treatment and longer retention in DATOS programs were positive predictors of posttreatment abstinence. The interactive effect of these 2 variables was also significantly positive. Programs that offered legal services and included recovering staff increased their clients' likelihood of cocaine abstinence. Crack use at both the client and program level predicted negative impact. None of the program variables assessed differentially affected the outcomes of first-timers and repeaters. Conclusions. Although treatment repeaters were relatively difficult to treat, their likelihood of achieving abstinence was similar to that of first-timers if they were retained in treatment for a sufficient time. First-timers and repeaters responded similarly to the treatment program characteristics examined. The treatment and policy implications of these findings are discussed.

Jacob, P. III, Yu, L.., Shulgin, A.T., & Benowitz, N.L. (1999). Minor Tobacco Alkaloids As Biomarkers For Tobacco Use: Comparison Of Users Of Cigarettes, Smokeless Tobacco, Cigars, And Pipes. AMERICAN JOURNAL OF PUBLIC HEALTH 89 (5): 731-736.
The Journal's Home Page: http://www.ajph.org/.
   ABSTRACT: Objectives. This study (1) determined levels of various tobacco alkaloids in commercial tobacco products; (2) determined urinary concentrations, urinary excretion, and half-lives of the alkaloids in humans; and(3) examined the possibility that urine concentrations of nicotine-related alkaloids can be used as biomarkers of tobacco use. Results. Alkaloid levels in commercial tobacco products, in milligrams per gram, were as follows: nicotine, 6.5 to 17.5; nornicotine, 0.14 to 0.66; anabasine, 0.008 to 0.030; and anatabine, 0.065 to 0.27. Measurable concentrations of all alkaloids were excreted in the urine of most subjects smoking cigarettes, cigars, and pipes and using smokeless tobacco. Correlations between nicotine intake and alkaloid concentrations were good to excellent. Conclusions. Anabasine and anatabine, which are present in tobacco but not in nicotine medications, can be used to assess tobacco use in persons undergoing nicotine replacement therapy.

Pierce, J. P., Gilpin, E. A., & Berry, C. C. (1998).   Has The California Tobacco Control Program Reduced Smoking? JAMA - JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION 280 (10): 893-899.
    The Journal's Home Page is:
http://jama.ama-assn.org/.

Tucker, K. L., Bianchi, L. A., & Bermudez, O. I. (1998). Adaptation of a Food Frequency Questionnaire to Assess Diets of Puerto Rican and Non-Hispanic Adults. AMERICAN JOURNAL OF EPIDEMIOLOGY 148 (5): 507.

Whitehead, M. (1998).  Food For Thought: Barriers To Healthy Eating. HEALTH EDUCATION JOURNAL 57 (2): 95.

Other References

Green, L.W., Frankish, C.J., McGowan, P., Ratner, P., Bottorff, J., Lovato, C.Y., Shoveller, J., Johnson, J., Williamson, D. (1999). Smoking Cessation: A Synthesis Of The Literature On Program Effectiveness. Vancouver: University of British Columbia, Institute of Health Promotion Research, for the BC Ministry of Health.
    A systematic review of the research literature on smoking cessation.
http://www.commhealth.ihpr.ubc.ca/mohscr/contents.pdf

World No-Tobacco Day --- May 31, 1999. Morbidity and Mortality Weekly Reports 48(19), May 21, 1999. http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/mm4819a1.htm
    The theme for this year's World No-Tobacco Day, May 31, is "Leave the Pack Behind." As part of World No-Tobacco Day, smokers are encouraged to quit, and governments, community organizations, schools, and families and friends are encouraged to help smokers quit. The projected increase in global mortality from tobacco use, from 3 million deaths in 1990 to 10 million in 2025, primarily represents mortality among persons who already smoke (1). Smoking cessation interventions can prevent many of these projected deaths. The World Health Organization (WHO) recommends that governments, community organizations, and health-care systems and professionals 1) make tobacco-use treatment an important public health priority; 2) offer practical interventions; 3) assess and document tobacco use and provide treatment as part of total health care; 4) fund proven treatments and make them widely available; 5) take responsibility for motivating smokers to quit and remain abstinent; 6) monitor tobacco use, and tax and regulate the sale and marketing of tobacco products; 7) invest in developing new treatments for nicotine dependence; and 8) encourage other professionals to set an example by quitting tobacco use (2). Additional information about World No-Tobacco Day 1999 is available from WHO's World-Wide Web site,
http://www.who.int/toh/worldnotobacco99/teaser.htm and CDC's Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, http://www.cdc.gov/tobacco
. References cited:
1. World Health Organization. Tobacco or health: a global status report. Geneva, Switzerland: World Health Organization, 1997.
2. World Health Organization. Statement on treatment for tobacco dependence. Available at: http://www.who.int/toh. Accessed April 14, 1999.

Illegal Sales of Cigarettes to Minors --- Ciudad Juárez, Mexico; El Paso, Texas; and Las Cruces, New Mexico, 1999. Morbidity and Mortality Weekly Reports 48(19), May 21, 1999.http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/mm4819a2.htm
    In 1996, the United States-Mexico Binational Commission (US-MBC) Health Working Group identified prevention of tobacco use, particularly among adolescents, as a priority and subsequently recommended joint efforts toward reducing illegal sales of cigarettes to minors. A 1997 survey of 561 commercial cigarette outlets in Mexico City found that 79% of retailers sold cigarettes to minors (1). To assess the illegal sale of cigarettes to minors in other regions of Mexico and on both sides of the U.S.-Mexico border, during January-February 1999 the General Directorate of Epidemiology in Mexico, the Chihuahua State Department of Health Services (CDH), the Ciudad Juárez Department of Health (CJDH), the Texas Department of Health (TDH), and the New Mexico Department of Health (NMDH) surveyed cigarette outlets in Ciudad Juárez, Mexico; El Paso, Texas; and Las Cruces, New Mexico. This report summarizes the results of these surveys, which indicate that almost all retailers in the surveyed outlets in Ciudad Juárez sold cigarettes to minors and that sales rates to minors were substantially lower in El Paso and Las Cruces. Reference cited:
1. CDC. Illegal sales of cigarettes to minors--Mexico City, Mexico, 1997. MMWR 1997;46:440-4.

Determination of Nicotine, pH, and Moisture Content of Six U.S. Commercial Moist Snuff Products --- Florida, January-February 1999. Morbidity and Mortality Weekly Reports 48(19), May 21, 1999. http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/mm4819a3.htm
    The use of smokeless tobacco (moist snuff and chewing tobacco) can cause oral cancer and precancerous oral lesions (leukoplakia) and is a risk factor for cardiovascular diseases and nicotine addiction (1). Despite these adverse effects, smokeless tobacco is used commonly in the United States by young people, especially male high school students (2). Officials in Florida requested CDC assistance in analyzing six moist snuff products to measure three factors that affect their nicotine dose: pH, nicotine content, and moisture content. This report summarizes the results of the analysis, which indicate that the pH, amount of nicotine, and moisture vary widely among brands. References cited:
1. US Department of Health and Human Services. The health consequences of using smokeless tobacco: a report of the advisory committee to the Surgeon General. Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, 1986.
2. CDC. Youth Risk Behavior Surveillance--United States, 1997. MMWR 1998;47(no. SS-3).


STUDY QUESTIONS, ACTIVITIES, AND EXERCISES
1. The Tragedy of the Commons revisited. Legislative initiatives (environmental supports) to protect the public against alcohol abuse can be compared to compulsory immunization laws that protect the public against communicable diseases. Despite their intent, both kinds of laws can be perceived as an infringement of civil liberties. How do both of these issues relate to the larger issue of the utilitarian concept of the greatest good for the greatest number of people?
2. Planning objectives. Objectives presented in this chapter for reduction of alcohol and other drug misuse, for smoking reduction, and for reduction of environmental tobacco exposure, can be used to consider strategies to achieve these in their communities. How does local data on these issues compare with national targets? What are the implications for planning community health interventions?
3. School health education. Contact the administrative offices for the school district in which you live. Determine whether any health education programs are provided to students in the area of alcohol use, smoking, nutrition practices or drug use. If a program exists, describe the nature of the program and the grade level of the students involved in the program. Explore the implementation realities of putting health education curriculum into practice.
4. Advertising. Obtain a copy of the last five issues of popular magazines such as Time or Newsweek. In each issue, how many advertisements appear for alcoholic beverages? For cigarettes? How many public service announcements appear in regard to alcohol use or smoking? What is the ratio of the number of alcohol and smoking ads to the total number of ads? What does this imply?
5. Economics of drug use. One approach to curtailing drug use focuses on demand for the drug: if we reduce the number of drug users, the demand for drugs will decline. Another approach to curtailing drug use focuses on the supply of drugs: if we eradicate marijuana crops and poppy fields, drug use will decline in response to reduced supply. Research and evaluate each of these arguments.

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